When an individual is self-extricated, they should be assessed for:

1. catastrophic hemorrhage
2. airway with in-line spinal immobilization (for guidance on airway management, refer to the NICE guideline on major trauma)
3. breathing
4. circulation
5. disability (neurological)
6. exposure and environment

On arrival at the scene of the incident, use a prioritizing sequence to assess individuals with suspected trauma, for example <C>ABCDE:

1. catastrophic hemorrhage
2. airway with in-line spinal immobilization (for guidance on airway management, refer to the NICE guideline on major trauma)
3. breathing
4. circulation
5. disability (neurological)
6. exposure and environment

At all stages of the assessment:

1. protect the individual's cervical spine with manual in-line spinal immobilization, particularly during any airway intervention and
2. avoid moving the remainder of the spine.

(NICE 2016, p.8; Level C)

Assess the individual for spinal injury, initially taking into account the factors listed below. Check if the individual:

1. has any significant distracting injuries
2. is under the influence of drugs or alcohol
3. is confused or uncooperative
4. has a reduced level of consciousness
5. has any spinal pain
6. has any hand or foot weakness (motor assessment)
7. has altered or absent sensation in the hands or feet (sensory assessment)
8. has priapism (unconscious or exposed male)
9. has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.

Assess the individual with suspected thoracic or lumbosacral spine injury using these factors:

1. age 65 years or older and reported pain in the thoracic or lumbosacral spine
2. dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
3. pre-existing spinal pathology (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis), or known or at risk of osteoporosis – for example, steroid use
4. suspected spinal fracture in another region of the spine
5. abnormal neurological symptoms (paraesthesia or weakness or numbness)
6. on examination:
   1. abnormal neurological signs (motor or sensory deficit)
   2. new deformity or bony midline tenderness (on palpation)
   3. bony midline tenderness (on percussion)
   4. midline or spinal pain (on coughing)
7. on mobilization (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs)

Emergency personnel or first responders should carry out or maintain full in-line spinal immobilization if:

1. a high-risk factor for cervical spine injury is identified and indicated by the Canadian C spine rule, or,
2. a low-risk factor for cervical spine injury is identified and indicated by the Canadian C spine rule, and the individual is unable to actively rotate their neck 45 degrees left and right, or,
3. indicated by one or more of the factors:
   1. age 65 years or older and reported pain in the thoracic or lumbosacral spine
   2. dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
   3. pre-existing spinal pathology (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis), or known or at risk of osteoporosis – for example, steroid use
   4. suspected spinal fracture in another region of the spine
   5. abnormal neurological symptoms (paraesthesia or weakness or numbness)
   6. on examination:
      1. abnormal neurological signs (motor or sensory deficit)
      2. new deformity or bony midline tenderness (on palpation)
      3. bony midline tenderness (on percussion)
      4. midline or spinal pain (on coughing)
   7. on mobilization (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs)

Do not carry out or maintain full in-line spinal immobilization if:

1. they have low-risk factors for cervical spine injury as identified and indicated by the Canadian C spine rule
2. they do not have any of the following factors:
   1. age 65 years or older and reported pain in the thoracic or lumbosacral spine
   2. dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
   3. pre-existing spinal pathology (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis), or known or at risk of osteoporosis – for example, steroid use
   4. suspected spinal fracture in another region of the spine
   5. abnormal neurological symptoms (paraesthesia or weakness or numbness)
   6. on examination:
      1. abnormal neurological signs (motor or sensory deficit)
      2. new deformity or bony midline tenderness (on palpation)
      3. bony midline tenderness (on percussion)
      4. midline or spinal pain (on coughing)
   7. on mobilization (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs)

When carrying out full in-line spinal immobilization in adults, manually stabilize the head with the spine in-line using the following stepwise approach:

1. fit an appropriately sized semi-rigid collar unless contraindicated by:
   1. a compromised airway
   2. known spinal deformities, such as ankylosing spondylitis (in these cases, keep the spine in the individual's current position).
2. reassess the airway after applying the collar
3. place and secure the individual on a scoop stretcher
4. secure the individual with head blocks and tape, ideally in a vacuum mattress.

(NICE 2016, p.8; Level C)

On arrival at the emergency department, use a prioritizing sequence protocol for assessing individuals with suspected trauma:

1. catastrophic hemorrhage
2. airway with in-line spinal immobilization (for guidance on airway management, refer to the NICE guideline on major trauma)
3. breathing
4. circulation
5. disability (neurological)
6. exposure and environment

At all stages of the assessment:

1. protect the individual's cervical spine with manual in-line spinal immobilization, particularly during any airway intervention, and
2. avoid moving the remainder of the spine.

(NICE 2016, p.11; Level B)

Emergency personnel and Emergency physicians should assess the individual for spinal injury if the individual:

1. has any significant distracting injuries
2. is under the influence of drugs or alcohol
3. is confused or uncooperative
4. has a reduced level of consciousness
5. has any spinal pain
6. has any hand or foot weakness (motor assessment)
7. has altered or absent sensation in the hands or feet (sensory assessment)
8. has priapism (unconscious or exposed male)
9. has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.

Carry out or maintain full in-line spinal immobilization in the emergency department if any of the factors below are present or if the assessment cannot be done:

1. significant distracting injuries
2. under the influence of drugs or alcohol
3. confused or uncooperative
4. has a reduced level of consciousness
5. has any spinal pain
6. has any hand or foot weakness (motor assessment)
7. has altered or absent sensation in the hands or feet (sensory assessment)
8. has priapism (unconscious or exposed male)
9. has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.

Suspected cervical spine injury: Assess the individual with suspected cervical spine injury using the Canadian C spine rule:

1. the individual is at high risk if they have at least one of the following high-risk factors:
   1. age 65 years or older
   2. dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example, diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
   3. paraesthesia in the upper or lower limbs
2. the individual is at low risk if they have at least one of the following low-risk factors:
   1. involved in a minor rear-end motor vehicle collision
   2. comfortable in a sitting position
   3. ambulatory at any time since the injury
   4. no midline cervical spine tenderness
   5. delayed onset of neck pain
3. the individual remains at low risk if they are:
   1. unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the individual is at low risk and there are no high-risk factors).
4. the individual has no risk if they:
   1. have one of the above low-risk factors and
   2. are able to actively rotate their neck 45 degrees to the left and right.

Carry out or maintain full in-line spinal immobilization and request imaging if:

1. a high-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule or
2. a low-risk factor for cervical spine injury is identified and indicated by the Canadian C spine rule, and the individual is unable to actively rotate their neck 45 degrees left and right or
3. indicated by one or more of the factors are present in those suspected in those with thoracolumbar or cervical spinal injury:
   1. age 65 years or older and reported pain in the thoracic or lumbosacral spine
   2. dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
   3. pre-existing spinal pathology (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis), or known or at risk of osteoporosis – for example, steroid use
   4. suspected spinal fracture in another region of the spine
   5. abnormal neurological symptoms (paraesthesia or weakness or numbness)
   6. on examination:
      1. abnormal neurological signs (motor or sensory deficit)
      2. new deformity or bony midline tenderness (on palpation)
      3. bony midline tenderness (on percussion)
      4. midline or spinal pain (on coughing)
      5. on mobilization (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs).

Do not carry out or maintain full in-line spinal immobilization or request imaging if:

1. they have low-risk factors for cervical spine injury as identified and indicated by the Canadian C spine rule, are pain-free and are able to actively rotate their neck 45 degrees left and right
2. they do not have any of the factors noted above as risk factors for thoracolumbar fracture

When carrying out or maintaining full in-line immobilization:

1. Tailor the approach to the individual's specific circumstances.
2. The use of spinal immobilization devices may be difficult (for example, in individuals with short or wide necks or individuals with a pre-existing deformity) and could be counterproductive (for example, increasing pain, worsening neurological signs and symptoms). In uncooperative, agitated, or distressed individuals, think about letting them find a position where they are comfortable with manual in-line spinal immobilization.
3. When carrying out full in-line spinal immobilization in adults, manually stabilize the head with the spine in-line using the following stepwise approach:
   1. Fit an appropriately sized semi-rigid collar unless contraindicated by:
      1. a compromised airway
      2. known spinal deformities, such as ankylosing spondylitis (in these cases, keep the spine in the individual's current position)
   2. Reassess the airway after applying the collar
   3. Place and secure the individual on a scoop stretcher
   4. Secure the individual with head blocks and tape, ideally in a vacuum mattress

For patients who are being transferred from an emergency department to another centre, provide verbal and written information that includes:

1. reason for the transfer
2. location of the receiving centre and the patient's destination within the receiving centre.
3. provide information on the linked SCI centre (in the case of cord injury) or the unit the patient will be transferred to (in the case of column injury or other injuries needing more immediate attention)
4. the name and contact details of the individual who was responsible for the patient's care at the receiving centre
5. results of ISCNCI examination, vitals, imaging examinations and risk for pressure injury development
6. the name and contact details of the individual responsible for the patient's care at the initial hospital.

After the individual with SCI has been stabilized, review the precipitating cause of the autonomic dysreflexia episode with the individual, family members, significant others, and caregivers to educate them regarding instigating factors, recognition, management, and prevention of future autonomic dysreflexia episodes.

1. Adjust the treatment plan to ensure that future episodes are recognized and treated to prevent a medical crisis or, ideally, are avoided altogether.
2. Discuss autonomic dysreflexia during the individual’s education program so that he or she will be able to minimize the risks known to precipitate autonomic dysreflexia, solve problems, recognize early onset, and obtain help as quickly as possible.
3. Have an ongoing conversation and continue education at annual evaluations or clinic appointments.
4. Give a written wallet card/guide or instruction sheet or consider a medical alert bracelet.

We recommend healthcare professionals with expertise in wound care provide training to healthcare professionals on preventing a pressure injury, including:

1. who is most likely to be at risk of developing a pressure injury
2. how to identify pressure damage
3. what steps to take to prevent new or further pressure damage
4. who to contact for further information and for further action.

Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure injury. Training should include:

1. how to carry out a risk and skin assessment
2. how to reposition
3. information on pressure redistributing devices
4. discussion of pressure injury prevention and management with patients and their caregivers
5. details of sources of advice and support
6. information regarding the importance of nutrition related to pressure injury prevention.

We recommend that CT of the spine is acquired if:

1. Imaging for cervical spine injury is indicated by the Canadian C-spine rule; or,
2. There is a strong suspicion of thoracic or lumbosacral spine injury associated with abnormal neurological signs or symptoms.

For imaging in adults (16 or over) with a head injury and suspected cervical spine injury, follow the recommendations in section 1.5 of the NICE guideline on head injury:
Investigating injuries to the cervical spine:

1. Be aware that, as a minimum, CT should cover any areas of concern or uncertainty on X-ray or clinical grounds.
2. Ensure that facilities are available for multiplanar reformatting and interactive viewing of CT cervical spine scans.
3. MR imaging is indicated if there are neurological signs and symptoms referable to the cervical spine. If there is suspicion of vascular injury (for example, vertebral malalignment, a fracture involving the foramina transversaria or lateral processes, or a posterior circulation syndrome), CT or MRI angiography of the neck vessels may be performed to evaluate for this.
4. In CT, routinely review on 'bone windows' the occipital condyle region for patients who have sustained a head injury. Reconstruction of standard head images onto a high-resolution bony algorithm is readily achieved with modern CT scanners.
5. In patients who have sustained high-energy trauma or are showing signs of lower cranial nerve palsy, pay particular attention to the region of the foramen magnum. If necessary, perform additional high-resolution imaging for coronal and sagittal reformatting while the patient is on the scanner table.
6. Criteria for performing a CT cervical spine scan in adults:
   1. For adults who have sustained a head injury and have any of the following risk factors, perform a CT cervical spine scan within 1 hour of the risk factor being identified:
   2. GCS less than 13 on initial assessment.
   3. The patient has been intubated.
   4. Plain X-rays are technically inadequate (for example, the desired view is unavailable).
   5. Plain X-rays are suspicious or definitely abnormal.
   6. A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
   7. The patient is having other body areas scanned for head injury or multi-region trauma.
   8. The patient is alert and stable, there is clinical suspicion of cervical spine injury, and any of the following apply:
      1. age 65 years or older
      2. dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorized recreational vehicles; bicycle collision)
      3. focal peripheral neurological deficit
      4. paraesthesia in the upper or lower limbs.
   A provisional written radiology report should be made available within 1 hour of the scan being performed.
7. Assessing the range of movement in the neck:
   1. Be aware that in adults who have sustained a head injury and in whom there is clinical suspicion of cervical spine injury, range of movement in the neck can be assessed safely before imaging only if no high-risk factors (see recommendations 1.5.8, 1.5.11 and 1.5.12) and at least 1 of the following low-risk features apply. The patient:
      1. was involved in a simple rear-end motor vehicle collision
      2. is comfortable in a sitting position in the emergency department
      3. has been ambulatory at any time since injury
      4. has no midline cervical spine tenderness
      5. presents with delayed onset of neck pain.

Computed tomographic angiography (CTA) is recommended as a screening tool in selected patients after blunt cervical trauma who meet the modified Denver Screening Criteria for suspected vertebral artery injury (VAI).
Modified Denver Screening Criteria for blunt cerebrovascular injuries:
Lateralizing neurologic deficit (not explained by CT head)

1. Infarct on CT head scan
2. Cervical hematoma (nonexpanding)
3. Massive epistaxis
4. Anisocoria/Homer’s syndrome
5. Glasgow Coma Scale score <8 without significant CT findings
6. Cervical spine fracture
7. Basilar skull fracture
8. Severe facial fracture (LeForte II or III only)
9. Seatbelt sign above the clavicle
10. Cervical bruit or thrill

In the awake patient with neck pain or tenderness and normal high-quality CT imaging or normal 3-view cervical spine series (with supplemental CT if indicated), the following recommendations should be considered:

1. continue cervical immobilization until asymptomatic
2. discontinue cervical immobilization following normal and adequate dynamic flexion/extension radiographs
3. discontinue cervical immobilization following a normal magnetic resonance imaging (MRI) obtained within 48 hours of injury (limited and conflicting Class II and Class III medical evidence), or
4. discontinue cervical immobilization at the discretion of the treating physician.

In the obtunded or unevaluable patient with a normal high-quality CT or normal 3-view cervical spine series, the following recommendations should be considered:

1. continue cervical immobilization until asymptomatic
2. discontinue cervical immobilization following a normal MRI study obtained within 48 hours of injury (limited and conflicting Class II and Class III medical evidence), or
3. discontinue cervical immobilization at the discretion of the treating physician.

Clinicians should assist individuals with SCI to establish a mechanism for regular performance of sitting support surfaces assessment specific to pressure injury prevention and treatment.
Schedule reassessment at least every two years, or sooner if any of the following occur:

1. health status changes, including weight or medical changes
2. changes in functional status
3. equipment wear or disrepair
4. pressure injury development
5. changes in living situation.

Be aware that, compared with the general population, individuals with SCI are likely to have the following systolic blood pressure differences:

1. In the supine resting position, adults with injuries at or above T1 will likely have low blood pressure (on average systolic blood pressure ~110 mmHg)
2. In the seated resting position, adults with injuries at or above T6 will likely have low blood pressure (on average systolic blood pressure ~100 mmHg)
3. Age-related changes in blood pressure (i.e., pediatric age group and older individuals) may be different.

Individuals with an SCI at or above T6 may present with the signs and symptoms of autonomic dysreflexia, including:

1. Elevated systolic blood pressure greater than 20 mmHg above their usual baseline in adults
2. Sudden-onset headache
3. Possible bradycardia or tachycardia
4. Cardiac arrhythmias, atrial fibrillation, premature ventricular contractions, and atrioventricular conduction abnormalities
5. Profuse sweating and/or flushing of the skin, typically (face, neck, and shoulders) or possibly below the level of the lesion
6. Piloerection (goosebumps) above or possibly below the level of the lesion
7. Blurred vision and/or spots in the individual’s visual fields
8. Nasal congestion
9. Feelings of apprehension or anxiety
10. Few or no symptoms other than elevated blood pressure

If fecal impaction is suspected, check the rectum for stool, using the following procedure:

1. Premedicate with a pharmacological agent.
2. With a gloved hand, generously instill a topical anesthetic agent, such as lidocaine jelly 2%, into the rectum.
3. Wait 3-5 minutes, if possible, for sensation in the area to decrease.
4. Then, with a gloved hand, insert a lubricated finger into the rectum and check for the presence of stool.
5. If present, gently remove, if possible.

If there is no fecal impaction or blood pressure elevation persists despite disimpaction, check for other less frequent causes of autonomic dysreflexia. If there are no obvious triggers or if the blood pressure cannot be managed locally, the individual must be referred to the hospital emergency department for evaluation, management and possible hospital admission. (PVA-AD 2020, p.642; Level C)

Autonomic dysreflexia has many potential causes. It is essential that the specific cause be identified and treated in order to resolve an episode of autonomic dysreflexia and to prevent recurrence. Any painful or irritating stimuli below the level of injury may cause autonomic dysreflexia. Bladder and bowel problems are the most common causes of autonomic dysreflexia. The following are some of the more common potential autonomic dysreflexia triggers:

• Bladder distention
• Bladder or kidney stones
• Blocked catheter
• Catheterization
• Detrusor sphincter dyssynergia
• Shock wave lithotripsy
• Urinary tract infection
• Urological instrumentation, such as cystoscopy or testing requiring catheterization

• Appendicitis
• Bowel distention
• Bowel impaction
• Gallstones
• Gastric ulcers or gastritis
• GI instrumentation
• Hemorrhoids

• Constrictive clothing, shoes, or appliances
• Contact with hard or sharp objects
• Blisters
• Burns, sunburn, or frostbite
• Ingrown toenail
• Insect bites
• Pressure injuries

• Sexual activity, including sexual intercourse
• Sexually transmitted diseases
• High sexual arousal and/or orgasmic release
• A second orgasmic release or ejaculation soon after the first orgasm will likely provoke more severe autonomic dysreflexia

• Ejaculation
• Epididymitis
• High-intensity vibrators used to induce ejaculation
• Priapism (especially from intracavernosal injection)
• Prostatitis
• Scrotal compression (sitting on scrotum)
• Sperm retrieval (EEJ and vibratory stimulation)

• Lactation, breastfeeding, mastitis
• Menstruation
• Painful intercourse and/or friction
• Pregnancy, especially labour and delivery, including ectopic pregnancy
• Vaginitis

• Boosting (an episode of autonomic dysreflexia intentionally caused by an athlete with SCI in an attempt to enhance physical performance)
• Deep vein thrombosis
• Excessive alcohol intake
• Excessive caffeine or other diuretic intake
• Fractures or other trauma below the level of injury
• Functional electrical stimulation
• Heterotopic bone
• Over-the-counter or prescribed stimulants
• Pulmonary emboli
• Substance abuse
• Sunburn
• Syringomyelia
• Surgical or invasive diagnostic procedures
• Unguis incarnatus

While the individual is being evaluated in the emergency department, continue to closely monitor blood pressure to guide pharmacological management of autonomic dysreflexia and investigate other causes. Consider hospital admission if:

1. There is poor response to the treatment specified above.
2. The cause has not been identified.

Following an episode of autonomic dysreflexia, a health care provider should consider the following:

1. If the individual is an inpatient or in the clinic, monitor closely for at least 2 hours for recurrent autonomic dysreflexia or hypotension.
2. If at home, instruct the individual to seek immediate medical attention if autonomic dysreflexia symptoms reoccur.
3. Prescribe a blood pressure monitoring device to the individual for home monitoring.

Document the episode of autonomic dysreflexia and record the effectiveness of the treatment in the individual’s medical record, including the following:

1. Presenting signs and symptoms and their course
2. Recordings of blood pressure and pulse
3. Treatment instituted and response to treatment
4. Restoration of blood pressure and heart rate to normal levels for the individual
5. Diagnosis of a history of autonomic dysreflexia in order to inform future clinicians of the risk in the individual and prior response to treatments initiated
6. Identification of the cause (trigger) of the autonomic dysreflexia episode
7. Whether the individual is comfortable, with no signs or symptoms of autonomic dysreflexia or secondary complications, such as neurological changes, increased intracranial pressure, or heart failure

After the individual with SCI has been stabilized, review the precipitating cause of the autonomic dysreflexia episode with the individual, family members, significant others, and caregivers to educate them regarding instigating factors, recognition, management, and prevention of future autonomic dysreflexia episodes.

1. Adjust the treatment plan to ensure that future episodes are recognized and treated to prevent a medical crisis or, ideally, are avoided altogether.
2. Discuss autonomic dysreflexia during the individual’s education program so that he or she will be able to minimize the risks known to precipitate autonomic dysreflexia, solve problems, recognize early onset, and obtain help as quickly as possible.
3. Have an ongoing conversation and continue education at annual evaluations or clinic appointments.
4. Give a written wallet card/guide or instruction sheet or consider a medical alert bracelet.

Consider instructing and prescribing pharmacological prophylaxis prior to sexual activity in selected individuals who:

1. Have no history of symptomatic orthostatic hypotension (OH)
2. Are not taking medication that may potentiate hypotension
3. Developed autonomic dysreflexia with systolic blood pressure at or above 150 mmHg (i.e., during vibratory stimulation, ejaculation, orgasm, sperm retrieval, or urological procedures)
4. Have symptomatic autonomic dysreflexia and/or systolic blood pressure greater than 150 mmHg prior to sexual activity or during sperm retrieval

Prior to the procedure, counsel the individual to:

1. Take prescribed medications (such as anticholinergic medications, alpha-blockers)
2. Have a recent bowel program (within 1-2 days)
3. Treat urinary tract infection, if present
4. Hold any as-needed medications that may elevate blood pressure (such as ephedrine, midodrine)
5. Hold any medications such as phosphodiesterase inhibitors (PDEis), which may not allow nitrates (nitropaste) to be used to treat autonomic dysreflexia

Consider referral for urgent investigation if individuals with SCI have any of the following ‘red flag’ signs and symptoms:

1. recurrent catheter blockages (for example, catheters blocking within 6 weeks of being changed)
2. hydronephrosis or kidney stones on imaging
3. biochemical evidence of renal deterioration (i.e., estimated eGFR-write out all algorithm).

Clinicians should undertake a general physical examination that includes:

1. blood pressure management
2. abdominal examination
3. external genitalia examination
4. vaginal or rectal examination (as indicated for evidence of pelvic floor prolapse, fecal loading or alterations in anal tone)
5. ISNCSCI assessment, if necessary
6. hand function
7. mobility
8. cognitive assessment

Offer individuals with neurogenic urinary tract dysfunction, their family members, and caregivers specific information and training. Individuals who are starting to use or are using a bladder management system that involves the use of catheters, appliances or pads, should:

1. receive training, support and review from healthcare professionals who are trained to provide support in the relevant bladder management systems and are knowledgeable about the range of products available,
2. have access to appropriate education on managing the daily and social needs of their bladder,
3. have access to a range of products that meet their needs, and
4. have their products reviewed at a maximum of 2 yearly intervals. SCI-U Patient Education Link on Bladder: http://sci-u.ca/bladder-2

The following conditions must be met before initiating a behavioural management program (e.g., timed voiding, bladder retraining or habit retraining) for those with neurogenic lower urinary tract dysfunction:

1. prior assessment by a healthcare professional trained in the assessment of individuals with neurogenic lower urinary tract dysfunction and
2. in conjunction with education about lower urinary tract function for the individual and/or their family members and caregivers.

Before offering an intravesical botulinum toxin type A:

1. explain to the individual and/or their family members and caregivers that a catheterization regimen is needed in most individuals with neurogenic lower urinary tract dysfunction after treatment
2. ensure that they are able and willing to manage such a regimen should urinary retention develop after the treatment

Routine surveillance cystoscopy for bladder cancer screening is not required in individuals:

1. with neurogenic lower urinary tract dysfunction;
2. with or without augmentation cystoplasty;
3. individuals who have no other signs or symptoms.

Individuals living with SCI should engage in at least: 20 minutes of moderate to vigorous-intensity aerobic exercise 2 times per week AND 3 sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, 2 times per week to improve cardiorespiratory fitness and muscle strength. (GINIS 2017, p.16; Level A)

• SCI Action Canada Resources: https://sciactioncanada.ok.ubc.ca/resources/
• Strength Training Exercises for Individuals with Paraplegia: http://fhsd-sciactioncanada-2019.sites.olt.ubc.ca/files/2019/11/home-strength-training-guide-paraplegia.pdf
• Strength Training Exercises for Individuals with Tetraplegia: http://fhsd-sciactioncanada-2019.sites.olt.ubc.ca/files/2019/11/home-strength-training-guide-tetraplegia.pdf
• Strength Training Videos for Individuals with Paraplegia or Tetraplegia: https://sciactioncanada.ok.ubc.ca/resources/active-homes/
• Activities for Power Wheelchair Users: https://sciguidelines.ubc.ca/tools-for- success/activity-examples/activities-for-power-wheelchair-users/

Clinicians may consider instituting the following nutritional measures in the post-acute period:

1. For all individuals with SCI, adopt a heart-healthy nutrition plan focusing on fruits, vegetables, whole grains, low-fat dairy, poultry, fish, legumes, non-tropical vegetable oils and nuts while limiting sweets and sugar-sweetened beverages, and red meats
2. Adopt the Dietary Approach to Stopping Hypertension (DASH) nutritional plan or Mediterranean nutritional plan if hypertension or additional cardiometabolic risk factors are present. DASH Nutritional Plan: https://www.heartandstroke.ca/get-healthy/healthy-eating/dash-diet

A registered dietician treating individuals with SCI living in a community setting should have SCI-specific nutrition and energy needs expertise and knowledge to conduct a nutrition assessment as part of the annual medical exam to develop and implement an individualized therapeutic nutrition plan. The nutrition assessment should include but is not limited to:

1. Food and nutrition-related history (specifically knowledge deficits, beliefs and attitudes, body image, mealtime behaviours, physical ability to self-feed, access to food- and nutrition-related supplies, meal preparation and food avoidances)
2. Anthropometric measurements (specifically body composition and weight)
3. Biochemical data, medical tests and procedures (specifically serum lipid and glucose levels)
4. Social history (specifically isolation)
5. Nutrition-focused physical findings (specifically bowel and bladder function).

Clinicians may consider assessing individuals with SCI for obesity beginning at discharge from rehabilitation:

1. Where possible, measure body composition using 3- or 4-compartment models to report obesity in adults with SCI until validated, clinically appropriate equations become available. Classify adult men with >22% body fat and adult women with >35% body fat as obese and at high risk for cardiometabolic disease.
2. A body mass index (BMI) ≥22 kg/m2 is the cut-off point when used as a surrogate marker for obesity in individuals with SCI. Adult men and women with BMI ≥22 kg/m2 are at high risk for cardiometabolic disease. Test at least every three years following initial assessment when tests are normal in asymptomatic adults with SCI.

Use a brief, valid measure that has good sensitivity to screen all patients for general anxiety and panic disorders:

1. early during the initial inpatient hospital or rehabilitation stay
2. as a repeat screen if indicated to assess persistence of symptoms or change in status
3. at the first post-discharge follow-up point
4. at future time points, depending on risk stratification factors such as prior positive anxiety screening results or preinjury history of psychological disorder.

Screen all individuals with SCI for major depression by using a brief, valid measure that has good sensitivity and specificity:

1. early during the initial inpatient hospital or rehabilitation stay
2. as a repeat screen if indicated to assess persistence of symptoms or change in status
3. at the first discharge follow-up point
4. at least annually or more frequently, depending on risk stratification factors such as prior positive screening results and chronic pain.

Screen all patients for common substance use disorders:

1. Before discharge into the community, use a brief, valid measure that has good sensitivity to screen for lifetime use of and problems with alcohol, other (illicit) drugs, tobacco, marijuana, and nonmedical use of prescription medications
2. depending on initial screening results and other risk factors, rescreen patients for recent substance use in outpatient rehabilitation or primary care.

Screen all patients for ASD within 1 month of SCI and for PTSD after the first month. Screening should occur:

1. early during an initial inpatient hospital or rehabilitation stay
2. as a repeat screen if indicated to assess persistence of symptoms or change in status
3. at the first post-discharge follow-up point
4. at future time points beyond 6 months, depending on risk stratification factors, such as being a veteran or other trauma-exposed professional or having subthreshold symptom severity on prior screening examinations.

Formally screen individuals with SCI for suicidal ideation by using a brief, standardized, evidence-based screening tool. Screen for suicidal intent and behaviour in individuals who report suicidal ideation. Screen:

1. early during the initial inpatient hospital or rehabilitation stay
2. as a repeat screen if indicated to assess persistence of symptoms or change in status
3. at an early discharge follow-up point, and
4. at least annually or more frequently depending on risk stratification factors.

Diagnosis of neuropathic pain, including its causes, should be informed by:

1. a complete patient history
2. a physical examination
3. the International Spinal Cord Injury Pain (ISCIP) Classification system
4. investigations.

A complete patient history should focus on determining the nature of pain symptoms that could indicate potentially reversible causes, aggravators and/or mimics of neuropathic pain, and the consequences of pain on function and quality of life. Essential elements of a complete patient history are the following:

1. Nature of pain: onset or triggering event, position or location, quality (for example, burning, electric shock-like), radiation, severity, timing (for example, constant or intermittent, spontaneous, or evoked) and aggravating or alleviating factors
2. Changes in neurologic status: changes in strength, sensation, or spasticity
3. Associated symptoms: ask about red flag signs and symptoms such as vasomotor instability (Red flags are serious underlying conditions that may cause, aggravate or mimic NP. Red flag indicators are symptoms and signs that suggest that a particular condition may be present. It is essential to identify red flags, as effective treatment could significantly improve or eliminate NP if managed appropriately and if left untreated may have serious adverse consequences for the patient).
4. Screening for interference: interference with sleep, physical function and mood or emotional function
5. Recent changes in health: new medical diagnoses such as diabetes and other conditions predisposing to polyneuropathy
6. Additional historical components: based on presentation and suspected etiology.

The physical examination should include, at a minimum, neurologic, skin, and musculoskeletal examinations. Additional systems should be examined based on symptoms. Essential elements of the physical examination are the following:

1. Vital signs
2. International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)
3. Reflexes, tone
4. Range of motion assessment of extremities, joint swelling or redness
5. Visual inspection of the skin for integrity
6. Calf measurement to assess for deep vein thrombosis
7. ISNCSCI autonomic standards.

Additional physical examination components may be included based on presentation, for example:

1. Primary abdominal region pain: abdominal screening examination
2. Respiratory involvement: chest assessment
3. Autonomic symptoms: assessment for etiology of autonomic dysreflexia (noxious stimuli).

Determining a specific etiology can be difficult and may require additional investigations. The selection of these investigations is geared towards the diagnoses of greatest clinical likelihood, and diagnostic tests are based on the presentation. It is essential to image the appropriate area of the spinal cord for all patients with any change in neurologic status, such as changes in neurologic level, tone, and reflexes. If any suspicion of urinary tract infection exists, it is important to perform a urinalysis and culture and sensitivity. Patients with primary abdominal region pain should have an abdominal ultrasound, radiography, or computed tomography as necessary to determine the source of the pain; blood work may include lipase, amylase, liver enzymes and kidney function tests. Signs and symptoms suggesting respiratory involvement could lead to further investigations such as chest assessment or radiography. In patients in whom pulmonary embolism is suspected, a computed tomography angiogram or ventilation/perfusion lung scan should be performed. Other investigations should be performed based on the differential diagnosis, as appropriate.

Assess for serious underlying conditions (red flags) that may cause, aggravate, or mimic neuropathic pain and that require further investigation and prompt medical review. (CANPAIN DIAG 2016, p.S10; Level C)

Red flags are serious underlying conditions that may cause, aggravate, or mimic neuropathic pain. Red flag indicators are symptoms and signs that suggest that a particular condition may be present. It is essential to identify red flags, as effective treatment could significantly improve or eliminate neuropathic pain if managed appropriately and, if left untreated, may have serious adverse consequences for the patient.

Red flag table: https://www.nature.com/articles/sc201689/tables/1

Assess and manage psychosocial factors (yellow flags) that may contribute to pain-related distress and disability. (CANPAIN DIAG 2016, p.S10; Level C)

Addressing psychosocial factors (yellow flag conditions) is essential for treatment success in an individual who has pain after SCI. Yellow flags can complicate and exacerbate the presentation of neuropathic pain and may contribute to pain-related distress and disability. Examples of yellow flag conditions or factors include the following:

1. Depressive symptoms
2. Altered appetite
3. Poor motivation to complete daily activities or work because of pain
4. Decreased participation in valued activities
5. Pre-existing pain problems with evidence of poor adjustment
6. Avoidance of activities associated with pain
7. Extensive periods of rest or bed rest
8. Evidence of catastrophic thinking, preoccupation with pain prognosis, significant anxiety, and panic symptoms
9. Use and dependence on alcohol or illicit substances
10. Increasing opioid dependence or misuse
11. Disruption of sleep quality and/or duration
12. Lack of support from family members towards pain and activity.

Address patient concerns, expectations and needs as part of the neuropathic pain assessment. (CANPAIN DIAG 2016, p.S11; Level C)

It is vital to remember that pain is subjective, and individuals differ in their expectations of treatment and needs with regards to pain. As a result, it is important to develop rehabilitation goals and the treatment plan in partnership with the patient. Goals of treatment, such as improvement in function, reduction in pain severity and improvement in mood, should be reviewed before initiating a particular treatment. Consider using SMART (Specific, Measurable, Agreed upon, Realistic and Time-based) goal methodology when setting treatment goals. Establishing specific treatment targets also allows evaluation of treatment benefits.

Standardized evaluation of treatment response should be carried out by the healthcare team at regular intervals. (CANPAIN DIAG 2016, p.S11; Level C)

Monitoring a patient’s response to treatment, including efficacy, tolerance, dose-escalation, and side effects, is vital to modifying any suboptimal treatments. Such modification should be performed as rapidly as feasible. Adverse events need to be balanced against treatment benefits when determining whether to continue treatment, and discussion with the patient should inform decision-making.

Comparing treatment targets with achieved outcomes helps determine whether continued use of a treatment is worthwhile. It is also important to assess domains of intensity, mood, and function when determining treatment success. In addition to the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS v2.0), supplementary standardized measures such as the opioid risk tool may be used to evaluate outcomes not contained in the data set. As some medications to treat neuropathic pain, such as opioids, are subject to misuse, it is important to monitor for aberrant behaviour, as this may indicate either misuse or inadequate pain control. The National Opioid Use Guideline Group provides additional recommendations for opioid use.

The evaluation of treatment response should include assessment of changes in pain intensity, mood and function using the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) v2.0. Evaluation also includes an assessment of adverse events, aberrant behaviour, and compliance. (CANPAIN DIAG 2016, p.S11; Level C)

Monitoring a patient’s response to treatment, including efficacy, tolerance, dose-escalation, and side effects, is vital to modifying any suboptimal treatments. Such modification should be performed as rapidly as feasible. Adverse events need to be balanced against treatment benefits when determining whether to continue treatment, and discussion with the patient should inform decision-making.

Comparing treatment targets with achieved outcomes helps determine whether continued use of a treatment is worthwhile. It is also important to assess domains of intensity, mood and function when determining treatment success. In addition to the ISCIPBDS v2.0, supplementary standardized measures, such as the opioid risk tool, may be used to evaluate outcomes not contained in the data set. As some medications to treat neuropathic pain are subject to misuse, such as opioids, it is important to monitor for aberrant behaviour, as this may indicate either misuse or inadequate pain control. The National Opioid Use Guideline Group provides additional recommendations for opioid use.

International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) v2.0: https://www.iscos.org.uk/uploads/sitefiles/Data%20Sets/Papers%20from%20Spinal%20Cord%20-Data%20Sets/ISCIBDS_Pain_2.pdf

All patients with new-onset or worsening pain need to be reassessed. (CANPAIN DIAG 2016, p.S11; Level C)

It is critical to pay particular attention to late-onset pain or sudden worsening of chronic pain. New-onset or worsening chronic neuropathic pain may require exclusion of treatable causes of the pain, assessment for new-onset red flag or yellow flag conditions and a full neuropathic pain assessment.

Delivery of care for neuropathic pain in individuals with SCI should be:

1. coordinated
2. interprofessional
3. timely
4. patient-centred
5. using a biopsychosocial framework
6. evidence-based.

Numerous factors affect the presentation of chronic pain, including psychosocial and environmental factors. Conversely, chronic pain can significantly affect function, mood, and social relationships. Therefore, management of chronic pain after SCI in patients with complex presentations requires an interprofessional or interdisciplinary team approach that incorporates medical, physical, educational and cognitive-behavioural components. Communication between healthcare providers, between healthcare providers and administrators, and between healthcare providers and the patient is a central tenet of coordination of care services.

A biopsychosocial framework should guide the structure of a program and individual care plans. This model considers the interplay between physiology, psychology and social factors on the pain experience that affects neuropathic pain outcomes for individuals with SCI.

As proposed by Strauss et al., evidence-based decisions are essential to advancing practice, with priority given to SCI-specific guidelines and studies.

An individual with SCI and either:

1. new-onset or worsening spinal cord injury-related neuropathic pain, and/or,
2. ongoing pain that is difficult to manage and/or,
3. dissatisfaction with their current pain management protocol,

should be screened and assessed by a clinician with experience in managing individuals with SCI. (SYS CARE 2016, p.S25; Level C)

It is essential to involve clinicians with SCI experience when working with patients who have SCI-related neuropathic pain, who present with any of the conditions outlined in Recommendation V.4.2. A clinician with SCI experience can recommend relevant referrals, assessments, investigations, and treatment steps as appropriate. If necessary, on the basis of the results of the assessment, then this individual can act as a gatekeeper to team-based care for SCI-related neuropathic pain. If a diagnostic workup is required to determine the etiology or triggers of neuropathic pain after SCI, it is essential to involve the rehabilitation medicine specialist to ensure that relevant conditions are considered, and that appropriate investigations are implemented.

Multidisciplinary care coordinated through an SCI rehabilitation team is recommended when significant functional impacts and/or significant psychological comorbidity factors resulting from neuropathic pain need to be addressed. Further, a detailed plan of care shared among healthcare providers needs to be implemented across primary, secondary, and tertiary services. (SYS CARE 2016, p.S25; Level C)

It is important to recognize that pain management strategies should also address the functional and psychological impacts of pain, as current treatments may not eliminate pain or even reduce it effectively. As patients should expect to live with some degree of pain and discomfort, it is essential that they learn to minimize the impact of these symptoms on their daily lives. Generally, delivery of comprehensive care through an SCI rehabilitation team has been shown to be central to improving SCI outcomes. Access to such a team is therefore essential to managing complex functional impacts and/or psychological comorbidity more effectively. Currently, the implementation of specialized treatments may require access to a specialized pain clinic. Open communication and coordination between pain specialists and the SCI specialist team is required. Moving forward, we recommend that, given the unique needs of the SCI population, these treatment options be available at SCI-specific rehabilitation facilities.

As patient needs evolve, team members may change over time. The team approach to patient care can improve access to care, quality of care, and cost-effectiveness. The team approach is effective in increasing diagnostic accuracy and timeliness of treatment, which can improve health outcomes and patient satisfaction while increasing resource utilization efficiency and job satisfaction for clinicians. In addition, the team approach can streamline communication with patients and families. It is also important to consider the role of telemedicine, e-consults, and other forms of distance communication to allow staff from specialized rehabilitation centers to continue to provide oversight when travel is a barrier to optimal care delivery, such as may occur for patients in rural areas.

The multidisciplinary team should develop a detailed and integrated rehabilitation care plan that includes a focus on neuropathic pain in alignment with Accreditation Canada 2014 standards (https://accreditation.ca/spinal-cord-injury-rehabilitation-services). Multidisciplinary care should take a patient-centred, goal-directed, holistic, and functional approach to pain management that incorporates the caregiver and/or significant other in the care plan. Members of the multidisciplinary team should include the various rehabilitation disciplines such as physiatry, physiotherapy, occupational therapy, psychology, social work, nursing, and other professionals as needed.

An individual with neuropathic pain as a result of SCI should be discharged from specialized care when three conditions are met:

1. a stable plateau has been reached in pain severity and/or pain-related functional status
2. an ongoing plan linked to resources and provider follow-up is in place
3. self-management techniques have been taught.

The goal at discharge from specialized care should be stable pain severity and optimized function relative to an individual’s ongoing pain severity. Complete alleviation of pain is not usually a realistic outcome. A stable plateau may be considered to have been reached when the care providers and the patient feel maximal gains have been reached, given the available time and resources, in managing pain and its impact on everyday functioning. Periodic reassessments by specialized care providers may be appropriate after discharge to ensure the stability of pain management.

The goal of self-management education is to equip the patient to manage pain as independently as possible.

The SCI rehabilitation team should engage in continuous quality improvement, including evaluation and feedback efforts regarding their pain management practices based on patient outcomes. The plan, which is part of the ongoing care for neuropathic pain management, must be available to the patient before discharge from rehabilitation, and the patient must be educated about its elements. The plan must also be provided to any post-discharge care providers at discharge and especially to the provider assuming primary management of the patient. Useful items to include in the discharge plan, depending on the complexity of the case and the team members involved in care, are current medication, a medication titration plan, a plan for future pain management, nonpharmacologic treatment modalities, scheduled ongoing rehabilitation visits, and suggestions for the timing of follow-up and re-referral to rehabilitation. As much as possible, a discharge plan should also remove barriers to accessing services and identify appropriate community resources for each patient. It is often possible to identify suitable resources by working with partner organizations and allied services.

It is essential to integrate the principles of self-management into the discharge plan and patient education, to support the maintenance of a patient’s function and stability of pain management after discharge. Self-management interventions commonly involve psychoeducation to develop or improve self-efficacy skills in goal setting, problem-solving, management of psychological consequences, medication management, symptom management, social support, and communication.

Techniques should be:

1. demonstrable or actionable by the individual,
2. matched to the individual’s abilities,
3. linked to further community support.

Evaluation of practice supports accountability and improvement. The subjective nature of pain and the challenging nature of successful pain management make continuous quality improvement critical to ensuring that the individual’s needs continue to be met and that resources are used appropriately. Essential elements of a quality improvement program are process and outcome indicators to demonstrate the status of practice change. Process indicators, such as monitoring measure implementation, should include intent and by target. Outcome indicators, such as a reduction in the intensity of an individual’s pain over time, should be measured using the International Spinal Cord Injury Pain Basic Data Set element on pain intensity to accurately assess change produced by practice activities.

Tramadol may be used for the reduction of neuropathic pain intensity among individuals with SCI. (Adapted from CANPAIN TREAT, p.S16; Level B)

Tramadol is recommended as second-line therapy for SCI-related neuropathic pain. A single randomized, placebo-controlled trial found a significant reduction in pain intensity with tramadol compared with placebo, but the evidence quality was downgraded because of wide confidence intervals. The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain is a useful resource for general information on opioid management and prescription considerations. Although tramadol is not a scheduled drug in Canada, in the United States, it is a Schedule IV drug.

The maximum daily dosage of tramadol is 400?mg, divided into up to four daily doses. Treatment is usually initiated at 50?mg QD or BID and titrated, based on efficacy and tolerability. Common adverse effects are sedation, nausea, and constipation. A slight increase in the risk of serotonin syndrome can be seen when tramadol is combined with other monoaminergic drugs such as tricyclic antidepressants.

Lamotrigine may be considered in those with incomplete SCI (AIS B, C, or D) for the reduction of neuropathic pain intensity. (CANPAIN TREAT, p.S16; Level B)

Evidence for the efficacy of lamotrigine has been demonstrated only in patients with incomplete SCI. As a result, lamotrigine is recommended as second-line therapy only in this population. One randomized placebo-controlled trial showed that lamotrigine significantly reduced the intensity of neuropathic pain for patients with incomplete SCI, but the evidence quality was downgraded because of wide confidence intervals.

Lamotrigine dosage was titrated to a maximum of 400?mg per day. Common adverse effects were dizziness, somnolence, headache, and rash. It should be noted that lamotrigine has a black box warning issued by the United States Food and Drug Administration (FDA) for serious skin rashes, including Stevens-Johnson Syndrome.

Transcranial direct current stimulation (tDCS) may be considered for reducing neuropathic pain intensity among individuals with SCI. (CANPAIN TREAT, p.S16; Level A)

tDCS is recommended as third-line therapy for patients with SCI-related neuropathic pain on the basis of four RCTs focused on neuropathic pain in patients with SCI. Minor side effects of tDCS include skin irritation, which can be minimized by preparing electrodes with saline and the skin with electrode cream and by increasing current gradually, and phosphene, the visual perception of a brief flash of light, which is not actually present, if an electrode is placed near the eye.

Combined visual illusion and transcranial direct current stimulation may be considered for reducing neuropathic pain intensity among individuals with SCI. (CANPAIN TREAT, p.S17; Level A)

The combination of visual illusion and tDCS is recommended as third-line therapy. The main side effects of this combined therapy included mild headache and fatigue.

The dorsal root entry zone (DREZ) procedure may be considered in exceptional circumstances and as a last resort for reducing neuropathic pain intensity among individuals with SCI. (CANPAIN TREAT 2016, p.S17; Level C)

Evidence of benefit for the DREZ procedure exists, but the risk of the procedure does not justify its use beyond exceptional circumstances. Risks associated with the DREZ procedure include paresis, neuropathy or radiculopathy, ataxia and a variety of surgical complications such as persistent incisional site pain, cerebrospinal fluid leak, wound infection, subcutaneous hematoma, and bacteremia.

SCI clinicians should discuss and consider the following principles to ensure sexual well-being:

1. Maximize inherent sexual potential prior to using medical interventions
2. Adapt to limitations with the use of medical therapies or sexual aids and
3. Remain open-minded during sexual adaptation.

Inform men with SCI about the full range of options for treating erectile dysfunction and develop an individualized treatment plan as needed. Educate men with SCI about:

1. oral medications, such as PDE5i, to treat erectile dysfunction
2. risks and benefits of vacuum devices for the treatment of erectile dysfunction
3. intracavernosal injections for the treatment of erectile dysfunction
4. Permanent penile prosthesis (also known as implantable penile protheses) for the treatment of erectile dysfunction when nonsurgical treatments are ineffective or unsatisfactory.

The education should be delivered by a trained or experienced healthcare professional and include:

1. the causes of a pressure injury
2. the early signs of a pressure injury
3. ways to prevent a pressure injury
4. the implications of having a pressure injury (for example, for general health, treatment options and the risk of developing pressure injuries in the future)
5. skin cleansing and care techniques
6. management of incontinence
7. frequency and techniques of skin inspection
8. frequency, duration, and techniques of recommended position changes
9. frequency, duration, and techniques of recommended pressure redistribution
10. nutrition as it relates to maintaining skin integrity
11. techniques and equipment used to prevent a pressure injury (i.e., support surfaces including mattresses and cushions).

Prescribe wheelchair seating systems for each individual with an SCI individualized to anthropometric fit that:

1. provide optimal ergonomics
2. provide maximal function
3. redistribute pressure
4. minimize shear
5. provide comfort and stability
6. reduce heat and moisture
7. enhance functional activity
8. inspect and maintain all wheelchair cushions at regularly scheduled intervals
9. replace wheelchair seating systems that are no longer effective.

Ensure proper bed positioning by using devices and techniques that are appropriate for the type of support surface and mattress and the individual's health status. Use pillows, cushions, and positioning aids to:

1. Bridge contacting tissues, including bony prominences
2. Unload bony prominences
3. Protect pressure injuries and vulnerable areas of skin. Do not use closed cut-outs in mattresses or donut-type cushions.

Consider a variety of factors for comprehensive pressure management when selecting a wheelchair cushion:

1. influence of cushion characteristics, including weight, on wheelchair performance
2. pressure-redistributing or offloading characteristics at bony areas
3. positioning capabilities for postural management in resting and dynamic positions
4. maintenance of a supported and symmetrical resting posture to prevent postural deterioration over time
5. adequate stability for function and prevention of long-term postural deterioration
6. microclimate management
7. shear and friction reduction at the user-cushion interface
8. comfort

Assess and prescribe options for other seating needs and provide recommendations for transfers and repositioning as part of the seating assessment to ensure that these surfaces and their use do not cause pressure injuries. These needs may include:

1. bathroom surfaces, such as a commode, toilet, shower bench, or other surfaces
2. seating options for travel
3. sports wheelchairs and seating for recreational and other activities
4. any other surface the individual may use other than the wheelchair.

Conduct an assessment of pressure injury risk factors in individuals with SCI on admission and reassess on a routine basis, as determined by the healthcare setting, institutional guidelines, and changes in the individual's health status.

1. demographic
2. SCI-related, such as incontinence
3. comorbid medical
4. nutritional
5. psychological, cognitive, contextual, and social
6. support surface for bed, wheelchair, and all durable medical equipment surfaces, such as shower/commode chair or bathroom equipment related. Use both a validated risk-assessment tool and clinical judgment to assess risk.

Upon identification of a pressure injury, perform an initial comprehensive assessment of the individual with a pressure injury, to include the following:

1. complete history and physical examination
2. complete skin assessment
3. laboratory tests (evaluate for infection and nutritional status)
4. psychological health, behaviour, cognitive status, and social and financial resources
5. availability and utilization of personal care assistance
6. positioning, posture, and equipment (e.g., wheelchair)
7. nutritional status
8. activities of daily living (ADLs), mobility, and transfer skills, as related to maintaining skin integrity
9. Home or living environment assessment

Describe and document in detail an existing pressure injury and its treatment. Include the following parameters:

1. anatomical location and general appearance
2. size of wound (length x width x depth)
3. category/stage
4. characteristics of the wound base: viable tissue (granulation, epithelialization, muscle, bone, or subcutaneous tissue), nonviable tissue (necrotic, slough, eschar)
5. infection (redness of the wound bed, temperature in the wound bed area, moisture and odour)
6. exudate amount and type
7. odour
8. wound edges (e.g., colour, raised, thickened, undermined, connected to wound bed, fistulas, pockets under the skin)
9. periwound skin (colour, temperature, dry, oily, intact, cracked, oedema).
10. wound pain
11. general condition (body temperature, autonomic dysreflexia changes, change in spasticity)
12. documentation of current treatment strategies and outcomes to date.

Establish a mechanism for a regular reassessment of the performance of sitting support surfaces specific to pressure injury prevention and treatment. Schedule reassessment at least every 2 years, or sooner if any of the following occur:

1. health status changes, including weight or medical changes
2. changes in functional status
3. equipment wear or disrepair
4. pressure injury development
5. changes in living situation.

Consider replacing the recumbent support surface with one that provides better pressure redistribution, offloading capabilities, shear reduction, and microclimate control for individuals who:

1. cannot be positioned off the pressure injury
2. have pressure injuries on at least two turning surfaces
3. fail to heal or demonstrate pressure injury deterioration despite appropriate comprehensive care
4. have a high risk of developing additional pressure injuries
5. bottom out on the existing support surface.

Cleanse pressure injury with each dressing change without harming healthy tissue on the wound bed:

1. use normal saline, sterile water, pH-balanced wound cleansers, lukewarm potable tap water.
2. use diluted sodium hypochlorite ¼ strength to ½ strength solution for wounds with heavy bioburden for a limited time only, until clinical evidence of bioburden is resolved.
3. use the following mechanical wound cleansing techniques to remove wound debris, exudates, surface pathogens, bacteria, and residue from topical creams and ointments.
4. 4–15 pounds per square inch (psi) pressure irrigation with angiocatheter attached to a syringe, spray bottle or pulsatile lavage.
5. gentle scrubbing of the wound bed with wet gauze.
6. cleanse peri-wound skin with normal saline, sterile water, pH-balanced skin cleanser, or lukewarm potable tap water with dressing changes.

Use a dressing that achieves a physiologic local wound environment that maintains an appropriate level of moisture in the wound bed:

1. control exudate
2. eliminate dead space
3. control odour
4. eliminate or minimize pain
5. protect the wound and the periwound skin
6. remove nonviable tissue
7. prevent and manage infection

Modify the treatment plan if the pressure injury shows no evidence of healing within 2 to 4 weeks. Review individual factors associated with non-healing of pressure injuries, such as the following:

1. incontinence
2. infection
3. carcinoma
4. abnormal wound healing
5. nutrition
6. medication
7. support surfaces
8. transfers
9. noncompliance

Assemble an interprofessional team to ensure optimal management of the individual and the pressure injury before, during, and after surgery, including:

1. selecting appropriate surgical candidates
2. performing a comprehensive assessment
3. implementing appropriate preoperative management
4. selecting the best surgical option and implementing it with expertise
5. planning and implementing optimal postoperative care.

Know and implement appropriate postoperative care after all pressure injury surgical repair:

1. assess and manage pain
2. evaluate support surfaces
3. position the individual to keep pressure off the surgical site
4. consider using an active bed surface when pressure on the surgical flap is unavoidable
5. consider using a Clinitron® air fluidized therapy bed after surgery
6. arrange a seating and postural assessment at the appropriate time during the postoperative mobilization period
7. progressively and gradually mobilize the individual to a sitting position over at least 4 to 8 weeks to prevent re-injury of the pressure injury or surgical site
8. provide education on pressure management and skin inspection.

Screen for common conditions, such as anemia, inflammation, diabetes, and hypothyroidism, which are known to delay healing, to ensure appropriate treatment. Perform the following tests:

1. complete blood count, including hemoglobin, hematocrit, white blood cell count, absolute lymphocyte count, serum albumin and description of red blood cell morphology
2. iron profile, including ferritin, serum iron, percentage saturation, and total iron-binding capacity
3. inflammatory markers: C-reactive protein, prealbumin and erythrocyte sedimentation rate
4. endocrine factors, including fasting or random blood glucose, hemoglobin A1C, and thyroid function tests.

Provide training to healthcare professionals on preventing a pressure injury, including:

1. who is most likely to be at risk of developing a pressure injury
2. how to identify pressure damage
3. what steps to take to prevent new or further pressure damage
4. who to contact for further information and for further action.

Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure injury. Training should include:

1. how to carry out a risk and skin assessment
2. how to reposition
3. information on pressure redistributing devices
4. discussion of pressure injury prevention with patients and their caregivers
5. details of sources of advice and support.

For assessment of the natural history of SCI disease, we recommend International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP), and self-care subscore of Spinal Cord Independence Measure (SCIM).

For interventions, if a reconstructive surgery, the ISHT and grasp and release test\TRI-HFT should be used at baseline and discharge. If stimulation therapies are being used to restore hand function, then use the TRI\HFT. (PRAXIS 2020; Level C)